Cervical spondylotic myelopathy(CSM) can lead to neurological dysfunction, severely impacting patients' activities of daily living and quality of life, and placing a heavy burden on patients and society (1–3). Posterior cervical laminoplasty is widely accepted as an effective treatment for multilevel CSM (4–6). In the early stage, sutures were used to fix the opened lamina, but their limited stability allowed the laminae to reclose over time, resulting in recurrent cord compression and compromised outcomes (7–9). The use of mini titanium plates has effectively addressed this issue. Titanium plates provide rigid postoperative support and maintain long-term laminar expansion (10).

In unilateral open-door laminoplasty, two principal mini-plate fixation strategies are used: all-level and alternative-level. Given the high cost of mini titanium plates, whether alternative-level fixation can match all-level fixation in efficacy and safety remains unclear.

This study systematically reviews the existing literature and uses a meta-analysis to compare the effectiveness and safety of skip fixation vs. continuous fixation of mini titanium plates in the treatment of multi-segmental cervical spondylotic myelopathy.

This study followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Our systematic review and meta-analysis indicates that both alternative-level and all-level laminoplasty achieve comparable clinical outcomes in the treatment of multilevel cervical myelopathy. Postoperative neurological improvements (JOA, JOA recovery) and pain relief(VAS) are similar between the two techniques, with no significant differences observed in functional recovery or complication rates. This suggests that, from a patient-centered clinical perspective, the efficacy and safety of alternate-level laminoplasty are on par with the traditional all-level approach. Both procedures effectively decompressed the spinal cord and led to satisfactory patient outcomes in the follow-up.

Despite these equivalent clinical results, our analysis reveals some radiographic differences between the two techniques. In general, all-level laminoplasty is associated with slightly better preservation of spinal canal expansion on imaging. For example, the all-level group tended to maintain a greater postoperative APD and a higher Pavlov's ratio at final follow-up. Similarly, the lamina open angle is better sustained in the all-level fixation group. At last follow-up, patients who underwent all-level laminoplasty had a marginally larger open angle compared to those with alternate-level fixation. These findings suggest that using plates at every level provides a more rigid and enduring support to keep the laminae open, thereby preventing the minor loss of canal expansion that can occur at alternative levels. In the alternate-level technique, the segments without a supporting plate experienced a slight inward settling of the lamina (11). These radiographic trends are consistent with the patterns reported in individual comparative studies (11, 13, 15) and highlight a biomechanical distinction: all-level fixation confers greater long-term stability to the expanded laminae.

The clinical relevance of these radiographic differences, however, appears limited within the follow-up periods reported. Although the alternate-level group showed statistically significant reductions in canal metrics (APD, Pavlov's ratio, open angle) over time, these changes were small in magnitude and did not translate into worse clinical outcomes in the studies analyzed. All included studies reported no significant between-group differences in postoperative neurological status or disability scores, despite the imaging disparities. In practical terms, even though all-level laminoplasty preserved slightly more canal space, the absolute canal dimensions achieved by alternate-level laminoplasty remained sufficient to prevent spinal cord recompression. Therefore, the statistically significant radiographic advantages observed with all-level fixation should be interpreted with caution—they may represent subclinical differences that have little impact on patient recovery. All-level laminoplasty does indeed provide more sustained spinal canal enlargement radiologically, but this incremental radiological advantage does not translate into significant clinical benefit. While using more implants results in higher surgical costs, patient subjective outcomes do not improve correspondingly.

Complications are categorized as overall complications, C5 palsy, and axial pain. There is no significant difference in the incidence of these complications between the two methods. The three analysis show low heterogeneity, indicating that the findings are robust. Although the absolute event count was small, the current evidence suggests that reducing plate density does not increase peri-operative or long-term complication rates. Nevertheless, large-scale, prospective studies with standardized complication definitions are required to verify equivalence within narrower confidence intervals.

In terms of sagittal parameters, CCI represents the physiological lordosis of the cervical spine and is closely related to the posterior spinous muscle complex. Since there is no difference in the degree of exposure between the two fixation techniques, final follow-up results showed no significant difference in CCI. Modified surgical techniques, such as C3 laminectomy (16, 17) or preserving muscles complex technique (18, 19), can further maintain the physiological lordosis of the cervical spine.

This meta-analysis incorporates four studies, all conducted at medical centers in China. Although this provides a degree of uniformity in patient pathology, surgical techniques, and peri-operative protocols, it also constrains the external validity of our findings. Regional variations in surgical preferences—such as hinge placement and titanium plate selection—along with differences in implant pricing structures, reimbursement policies, and patient anatomical characteristics, may affect both the feasibility of alternative-level fixation and its radiographic or clinical outcomes (e.g., baseline sagittal alignment parameters). Therefore, the pooled results presented here should be considered hypothesis-generating when applied outside the Chinese clinical context. Prospective, multicenter investigations across diverse healthcare systems are needed to determine whether these conclusions can be generalized globally.

In our meta-analysis, several outcomes—most notably cost (I² = 96%)—demonstrated a high level of statistical heterogeneity. The cost heterogeneity likely stems from variations among hospitals and regions, as well as differences in the study time window. Radiological parameters, such as open angle (I² = 45%) and, to a lesser extent, APD (I² = 35%), may show heterogeneity because of differences in hinge placement, plate specifications, and follow-up duration. We employed random-effects models for all outcomes with I² > 50%, yet multi-center prospective studies are still required to reduce this uncertainty further.

Limitations: (1) The number of included studies is limited, with only Four studies incorporated into the meta-analysis, and the sample size is relatively small, resulting in several outcomes with P values between 0.05 and 0.10 and potential corresponding risk of type II error. Four studies are all retrospective studies. High-quality randomized controlled trials can provide a higher level of evidence. (2) All eligible studies are from China. Although the enrolled populations are relatively homogeneous, the findings may not be generalizable to regions with different surgical training paradigms, implant markets, or patient demographics. Future randomized controlled trials or well-designed prospective cohort studies from diverse geographic settings are needed to further validate these conclusions. (3) This study only included publicly published literature in English, lacking literature in other languages. (4) Some of the included indicators, such as ROM and Pavlov's ratio, have an insufficient number of studies, with only two studies reporting relevant content. This may also introduce bias.

Alternative-level laminoplasty is comparable to all-level laminoplasty in intraoperative outcomes (operative time, blood loss), safety (complications, C5 palsy, axial symptoms), clinical efficacy follow-up(JOA, JOA recovery, VAS) and sagittal parameters(CCI, ROM). Alternative-level is inferior in cervical canal outcomes (APD, Pavlov`s ratio, open angle). It is superior in cost. Four included studies are all single-center retrospective investigations from China, the evidence level is limited, and regional variations in surgical preferences, implant pricing, and patient anatomy may restrict external generalizability. Accordingly, surgical decisions should be individualized, balancing cost savings against the need for adequate decompression, and high-quality multicenter randomized controlled trials across diverse health-care systems are urgently needed to validate these findings.